Healthcare Provider Details

I. General information

NPI: 1720856206
Provider Name (Legal Business Name): MARIO YOUNG NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 HANCOCK CT NE STE B
ALBUQUERQUE NM
87109-4594
US

IV. Provider business mailing address

7401 HANCOCK CT NE STE B
ALBUQUERQUE NM
87109-4594
US

V. Phone/Fax

Practice location:
  • Phone: 505-322-2510
  • Fax:
Mailing address:
  • Phone: 505-553-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77098
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: